North Star Insurance Services, LLC - Insuring your future

Free Insurance Quotes for Home, Auto, and Life Insurance

Life Insurance Quote

We would like to provide you with a free, no-obligation life insurance quote. Please provide as much information possible for the most accurate quote. This information will be kept confidential and will be used for quote purposes only.

This Online Application is on a Secure Server. Click on the seal on the
left for more information on the certificate's authentication.

Privacy Statement: Any information provided by a consumer or
customer via our online forms WILL be held in the strictest confidence. No
information will be shared with others. All submissions will be responded to
within two business days.

General Information

Name:

Address:

City:

State:
Zip:

Day Phone:

Night Phone:

Best Time To Call:

AM
PM

Email Address:

Information About Yourself And Family

Please enter information below for all to be covered.

Self

Spouse

Child #1

Child #2

Child #3

Name:

Self

Date ofBirth:

Sex:

M
F

M
F

M
F

M
F

M
F

Marital Status:

M
S

M
S

M
S

M
S

M
S

Occupation:

Height:

ft. in.

ft. in.

ft. in.

ft. in.

ft. in.

Weight:

lbs.

lbs.

lbs.

lbs.

lbs.

Have you (they) had any of the following health conditions:

Heart
CancerDiabetes
HBP

Heart
CancerDiabetes
HBP

Heart
CancerDiabetes
HBP

Heart
CancerDiabetes
HBP

Heart
CancerDiabetes
HBP

Please enter information below about TOBACCO usage for all to be covered.

Have you (they) ever used tobacco or nicotine products?:

Never
Present
Quit**

Never
Present
Quit**

Never
Present
Quit**

Never
Present
Quit**

Never
Present
Quit**

Type of Tobacco used?:

smokeless
cigar
cigarette
pipe
patch/gum

smokeless
cigar
cigarette
pipe
patch/gum

smokeless
cigar
cigarette
pipe
patch/gum

smokeless
cigar
cigarette
pipe
patch/gum

smokeless
cigar
cigarette
pipe
patch/gum

Packs per day:

# of yrs smoked:

**Quit -- Please enter information if any to be insured are FORMER TOBACCO users.

**QuitMonth/Year:

Packs per day:

Years smoked?:

Individual Histories

Please list any individual histories on each person to be covered.

Self

Is person to be insured currently on any prescription medications forongoing health conditions?
Yes
No If yes, please list below.
Also, please DISCLOSE any and all health conditions you have (or had in the past):

Spouse

Is person to be insured currently on any prescription medications forongoing health conditions?
Yes
No If yes, please list below.
Also, please DISCLOSE any and all health conditions they have (or had in the past):

Child #1

Is person to be insured currently on any prescription medications forongoing health conditions?
Yes
No If yes, please list below.
Also, please DISCLOSE any and all health conditions they have (or had in the past):

Child #2

Is person to be insured currently on any prescription medications forongoing health conditions?
Yes
No If yes, please list below.
Also, please DISCLOSE any and all health conditions they have (or had in the past):

Child #3

Is person to be insured currently on any prescription medications forongoing health conditions?
Yes
No If yes, please list below.
Also, please DISCLOSE any and all health conditions they have (or had in the past):

Life Coverages

Self

Spouse

Child #1

Child #2

Child #3

Amount ofCoverage:

$

$

$

$

$

Type ofCoverage:

Term
Whole
Universal

Term
Whole
Universal

Term
Whole
Universal

Term
Whole
Universal

Term
Whole
Universal

DisabilityIncome:

Y
N

Y
N

N/A

N/A

N/A

Long TermCare:

Y
N

Y
N

N/A

N/A

N/A

Additional Comments

Please give any additional comments you feel appropriate for this
quotation. If you have additional children or other information where there
was not enough space, please enter them here.

Please click on the "Submit Quote" button to send your quote request. One of our representatives will respond to your submission as soon as possible.

Important Note: This website provides only a simplified description of coverages and is not a statement of contract. Coverage may not apply in all states. For complete details of coverages, conditions, limits and losses not covered, be sure to read the policy, including all endorsements.